When asked about
ambulation, patient reported that he had been walking a few times a day but that
his legs felt weak after “a few minutes of walking.”

Objective:

Two medications that the patient receives (Lotensin and Bumex) have muscle weakness
and/or muscle pain as adverse effects.

Problem

Impaired walking

Long Term:

Patient will be
able to ambulate around home with no report of weakness by [date].

Nursing student will make referrals for home
health aide services for assistance with ADLs. Walking impairment may serve as a
barrier to self-care, including eating and drinking.

I

Patient was to be D/Ced
to his home 02/05/08 with a home health service of his choice.Goal is on track to be met.

Nursing student encouraged
patient to perform ROM exercises each day in addition to exercises shown by home
health providers.

R/T

insufficient muscle strength

Short Term:

Patient will ambulate
3 times, with assistance, to the end of the hallway and back to his room on [date].

Nursing student will collect baseline pulse rate/rhythm before walking clients,
and reassess after 5 minutes of walking. If either are abnormal, have the client
sit for 5 minutes then retake pulse rate. If it is still abnormal, walk clients
more slowly and with more help, or for a shorter time. Pulse rate indicates cardiac
tolerance; if it rises too high after a few walking trials, the physician should
be notified.

Patient reported that he had been ambulating a few times a day. Patient was to be
sent home on 02/05/08 so he would probably not have time to ambulate the hallways
3 times before D/C. Goal not met.

. Pt had full
strength in bilateral UE, but reported weakness in bilateral LE upon standing/walking.
Had sensation in all extremities equal bilaterally. Skin color consistent with genetic
background. Warm dry to touch. Bilateral feet and toes cool to touch. ADQ turgor.
No abnormal heart sounds upon auscultation, regular rate and rhythm. Capillary refill
less than 3 seconds in bilateral UE and LE. Radial and pedal pulses 2+ with equal
rate bilaterally. No adventitious lung sounds heard. Respirations were even, unlabored
at a rate of 16 bpm. Pt has no diet restrictions. BMI 49.9 at 500lbs. Hyperactive
bowel sounds. Soft, rounded abd. Last BM on afternoon of [date]. Pt ate 100% of
morning meal. Expressed financial concerns regarding his hospitalization. He had
been laid off from his previous employer and his wife is currently in
school.